Basic Information
| Provider Information | |||||||||
| NPI: | 1154463495 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLEGANY COUNTY HEALTH DEPARTMENT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ACHD-OUTPATIENT MENTAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1745 | ||||||||
| Address2: | |||||||||
| City: | CUMBERLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 215011745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017595000 | ||||||||
| FaxNumber: | 3017775674 | ||||||||
| Practice Location | |||||||||
| Address1: | 12501-12503 WILLOWBROOK RD | ||||||||
| Address2: | |||||||||
| City: | CUMBERLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017595280 | ||||||||
| FaxNumber: | 3017775630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 07/31/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RAVER | ||||||||
| AuthorizedOfficialFirstName: | SUE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | HEALTH OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3017595001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALLEGANY COUNTY HEALTH DEPARTMENT | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD, MPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 6184 | MD | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0801X | 6185 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 351541 | 01 | ALLIANCE-MAMSI | OTHER | 604116-01 | 01 | CAREFIRST | OTHER | 263361200 | 05 | MD | MEDICAID | CN8432 | 01 | MEDICARE-TRAVELERS | OTHER | PVPB127031 | 01 | APS | OTHER | 418764400 | 05 | MD | MEDICAID | PK6 | 01 | CAREFIRST-FEDERAL | OTHER |